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Date: July 31, 2024

Reference:  Gonzales RE, Seeburger EF, Friedman AB, and Agarwal AK. Patient perceptions of behavioral flags in the emergency department: A qualitative analysis. AEM July 2024

Guest Skeptic: Dr. Neil Dasgupta is an emergency medicine physician and ED intensivist from Long Island, NY. He is the Vice Chair of the Emergency Department and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County.

Case: You’re three coffees deep into your night shift when emergency medical services (EMS) bring in a highly agitated 34-year-old male patient with a questionable psychiatric history and possible substance use.  He is actively fighting with the police and EMS personnel.  The paramedic apologizes to you, saying the patient was picked up while having a loud verbal altercation that was about to turn violent and he was unable to administer any medications or get a story, let alone intravenous (IV) access, even with eight police officers on scene.  While you do not recognize the patient, your colleague on the other team comes over and says to you “Oh, I know that guy, he’s a real piece of work.  Be careful you don’t get hurt!  Don’t you wish we got a heads up about these kinds of patients in the chart?”

Background: Violence in emergency departments (EDs) has reached alarming levels, creating significant challenges for healthcare professionals. In an American College of Emergency Physicians (ACEP) survey from August 2022, two-thirds of emergency physicians reported being assaulted in the past year with one-third resulting in injury.[1]

This disturbing trend has only been exacerbated by the COVID-19 pandemic, which has intensified stress levels, overcrowding, and labour shortages in hospitals. In a 2024 poll of ACEP members, 91% of emergency physicians said that they, or a colleague, was a victim of violence in the past year. A supermajority (68%) of those emergency physicians said they did not feel their employer’s response was appropriate and half reported nothing was done about the violence.[2]

Violence in the ED is not just directed against physicians. A 2024 survey by the Emergency Nurses Association (ENA) found that more than half of its members reported being verbally assaulted, threatened with violence, or physically assaulted in the previous 30 days. Additionally, a Press-Ganey analysis indicated that two nurses are assaulted every hour. It’s estimated that up to 80% of workplace violence cases involving nurses go unreported, suggesting that the actual incidence of violence is likely much higher than reported figures.[3]

​The violence faced by emergency healthcare workers has profound impacts, including physical injuries and psychological trauma. Many healthcare workers report experiencing severe stress and burnout due to these violent encounters. Studies indicate that the rate of serious injuries from workplace violence is six times higher for hospital workers than for all other private sector employees in the United States​.[4]

In response to this unacceptable violence in the ED, there have been calls for legislative action. The “Workplace Violence Prevention for Health Care and Social Service Workers Act” and the “Safety From Violence for Healthcare Employees Act” (SAVE) are two key pieces of legislation aimed at mitigating workplace violence and establishing federal criminal penalties for assaults on healthcare workers. These efforts are supported by organizations like the ENA, ACEP, and the American Nurses Association (ANA)​.[5]

To address the issue of ED violence, various strategies have been recommended, including better training in de-escalation techniques, improved reporting systems, and more robust workplace violence prevention programs. There is also an emphasis on supporting healthcare workers’ decisions to refuse care in dangerous situations and ensuring that law enforcement is involved in managing violent incidents​.[6]

ED violence is unfortunately not an isolated problem in the USA with other countries facing similar issues. The Canadian Association of Emergency Physicians (CAEP) has a position statement on ED violence.[7] This document highlights the serious problem of workplace violence in EDs, emphasizing the need for enhanced safety measures and support for healthcare providers. These include increased security measures, staff training in de-escalation techniques, and the implementation of policies to protect healthcare workers.

The underlying cause for the rise in ED violence is likely multifactorial, including difficulties for patients accessing medical and psychiatric care, increasing burdens on ED with significant overcrowding, a highly stressed and under-resourced health care delivery system and perpetual staffing concerns. 

Several interventions have been developed to address the issue of ED violence. These have ranged from zero-tolerance policies to engaging with violent patients. [6] However, a Cochrane SRMA reported a lack of evidence that any of these interventions are effective at mitigating healthcare violence.[8]  One strategy that was not reviewed in the Cochrane publication was the use of behavioural flags in the electronic health record (EHR) to alert clinicians that a patient had a violent or unsafe event in a prior visit. 

While there are positive aspects to an early warning system for ED staff, there is a concern that existing bias or inequity in our system may negatively impact our patients when using such behavioural flags.

Clinical Question: How would patients in the emergency department feel about the use of behavioural flags in the EHR and their utility as a strategy to mitigate violent or unsafe events?

Reference:  Gonzales RE, Seeburger EF, Friedman AB, and Agarwal AK. Patient perceptions of behavioral flags in the emergency department: A qualitative analysis. AEM July 2024

  • Population: Emergency department patients
  • Interest: The use of behavioral flags in the EHR to identify the risk of unsafe events
  • Context: Patient perceptions of the use of behavioral flags as a method of risk reduction for ED violence and better management of aggressive or unsafe patient behaviors
  • Type of Study: Thematic analysis of semi-structured interviews

Rachel Gonzales

This is an SGEM HOP and we are pleased to have the lead author on the show Rachel Gonzales. She is a research project manager at the Center for Health Care Transformation and Innovation and the Department of Emergency Medicine at the University of Pennsylvania. Rachel is passionate about identifying new solutions to promote equity in health care and increase access to health and health care for underserved populations.

Authors’ Conclusions: “While many saw flags as a helpful tool to mitigate violence, concerns around negative impacts on care, transparency, and equity were also shared. Insights from this stakeholder perspective may allow for health systems to make flags more effective without compromising equity or patient ideals.”

Quality Checklist for Qualitative Studies:

  1. Was there a clear statement of the aims of the research? Yes
  2. Is a qualitative methodology appropriate? Yes
  3. Was the research design appropriate to address the aims of the research? Yes
  4. Was the recruitment strategy appropriate to the aims of the research? Unsure
  5. Was the data collected in a way that addressed the research issue? No
  6. Has the relationship between the researcher and participants been adequately considered? Yes
  7. Have ethical issues been taken into consideration? Yes
  8. Was the data analysis sufficiently rigorous? Yes
  9. Is there a clear statement of findings? Yes
  10. How valuable is the research? Unsure
  11. Financial conflicts of interest. No

Results: This qualitative analysis included 25 adult patients in the ED of a large, urban, academic medical center who had no history of a behavioral flag in their EHR. The mean age was 49 years, 56% were male, 72% identified as Black or African American, 24% as White, and 4% as Asian and participants reported various levels of education.

Key Results: They identified five major themes from the potential benefits of behavioural flags, the potential harms, transparency of flags, equity and some ideas to improve the flag system.

Five Major Themes:

  1. Potential Benefits: Participants saw behavioral flags as useful for improving the knowledge or care of patients, mitigating violence, and signalling patients to improve their behavior. They believed flags could provide better understanding and preparedness for healthcare providers, which could enhance patient care and safety.
  2. Potential Harms: Participants expressed worries that flags could misrepresent a patient’s true character or behavior, negatively impact care seeking, and lead to substandard care. They feared that flags might label patients unfairly based on isolated incidents or subjective judgments, potentially discouraging them from seeking future care and affecting the quality of care they receive.
  3. Transparency and Patient Awareness: There was a strong sentiment that patients should be informed if a flag is placed in their chart. However, concerns were also raised that informing patients might escalate the situation, leading to potential conflicts during the ED visit.
  4. Equity: Participants highlighted issues of bias and inequity in flag placement, with concerns that racial disparities observed in the placement of flags could perpetuate inequitable treatment. They noted that cultural or class differences could also contribute to these disparities.
  5. Ideas for Improvement: Suggestions for improving the flag system included considering the context and circumstances when placing a flag, taking further action when a flag is present to ensure safety, incorporating patient input or perspective into the flagging process, and making improvements outside of behavioral flags, such as increasing security and training for staff on de-escalation and conflict resolution.

Listen to the SGEM podcast to hear Rachel respond to our five nerdy questions.

1. Participants: This was a convenient sample of adult patients from a single-center urban ED who were stable enough to participate in an extended interview and had no history of behavioral flags is interesting. It seems the authors were interested in a general ED patients’ perspective rather than the perspective of patients who would be affected directly by such a behavior flag being placed on their EHR. 

2. Education Level: The guide for the semi-structured interviews was written with a Flesch Kincaid grade level of over 12, raising concerns about a significant disconnect between the education/literacy level of the patient population being interviewed and the questions posed. Participants reported various levels of education, with some high school (4%), high school graduates (28%), some college (20%), associate degree (4%), bachelor’s degree (8%), postgraduate degree (4%), and unknown education level (32%). The authors attempted to mitigate this by allowing the interviewer to explain/rephrase, but this design choice seemed suboptimal.

3. Race: The racial makeup of the study population is overwhelmingly Black/African American (72%), reflecting the patient demographics of the single center in the study. This likely led to a greater emphasis on racial bias and inequity as recurrent themes in the analysis.

4. Bias: Behavioral flags perform a function within the EHR that could alternatively performed with a cursory chart review by clinicians on patient arrival, resulting in similar concerns about inequity and bias. The semi-structured interview directly addressed disproportionate numbers of Black patients receiving flags, but it is unclear if this underlying idea that prior chart review would have an equivalent effect was addressed.

5. Potential Researcher Bias: The interviewer and coders have diverse backgrounds in public health, which could influence data interpretation. Efforts were made to minimize bias through double coding and ongoing discussions, but some subjectivity is inherent in qualitative analyses.

Comment on Authors’ Conclusion Compared to SGEM Conclusion:  We generally agree with the authors’ conclusion.

SGEM Bottom Line: Behavioral flags on patients’ charts have the potential for both benefit and harm, and it is unclear what the net impact would be on violence in the ED and patient care.

Case Resolution: After effectively de-escalating the patient with soothing words, reassurance of safety and midazolam, you send an e-mail to your medical director asking if adding a behavioral flag in the EHR may help alert clinicians to patterns of violent behavior.  She asks that you participate in a committee meeting to present your perspective since the institution has already considered this and is about to roll out a trial.

Dr. Neil Dasgupta

Clinical Application: Adding a behavioral flag to a patient’s record has the potential of negatively affecting that patient’s care by introducing more bias in a complex medical system that has existing underlying bias and inequity.  This must be balanced by the potential benefit of de-escalating unsafe situations and preventing violence in the ED.  Understanding patients’ perspectives and incorporating their input when implementing these systems can allow us to care for patients better and prevent potential harm. So, while the use of behavioral flags can alert clinicians to potentially dangerous interactions, we must be mindful of how it may affect the patient and the physician-patient relationship.

What Do I Tell the Patient?  You may not tell the patient anything or may disclose the flag after the fact. This will depend on your hospital/department policies but should be addressed when such a flag is instituted.

Keener Kontest: There was no winner last week. There are >550 clinical decision tools currently on the website www.MDCalc.com. 

Listen to the SGEM podcast to hear this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on putting behavior flags on the EHR? Tweet your comments using #SGEMHOP.  What questions do you have for Rachel and her team Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

  1. ACEP ED Violence is on the Rise. Accessed July 24, 2024 https://www.emergencyphysicians.org/article/er101/poll-ed-violence-is-on-the-rise
  2. ACEP ED Violence Overview. Accessed July 24, 2024. https://www.acep.org/administration/ed-violence-stories/ed-violence-stories-overview
  3. ENA Sounds Alarm About Violence Against ED Nurses. Accessed July 24, 2024. https://www.ena.org/press-room/2024/03/22/ena-sounds-alarm-about-violence-against-ed-nurses
  4. ANA, ENA & ACEP Sound the Alarm on Violence Against Nurses. Accessed July 24, 2024.https://www.nursingworld.org/news/news-releases/2024/ana-ena–acep-sound-the-alarm-on-violence-against-nurses/
  5. ACEP Protecting Emergency Physicians from Violence in the ED. Accessed July 24, 2024. https://www.acep.org/siteassets/new-pdfs/advocacy/lac24-ed-workplace-violence-one-pager.pdf
  6. Spelten E, van Vuuren J, O’Meara P, Thomas B, Grenier M, Ferron R, Helmer J, Agarwal G. Workplace violence against emergency health care workers: What Strategies do Workers use? BMC Emerg Med. 2022 May 6;22(1):78. doi: 10.1186/s12873-022-00621-9. PMID: 35524175; PMCID: PMC9074314.
  7. CAEP Position Statement on Violence in the Emergency Department. Accessed July 24, 2024. https://caep.ca/wp-content/uploads/2020/01/CAEP-ED-VF2-ACRLJan-16-VIOLENCE-DRAFT-Ver-2-3.pdf.
  8. Spelten E, Thomas B, O’Meara PF, Maguire BJ, FitzGerald D, Begg SJ. Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates. Cochrane Database Syst Rev. 2020 Apr 29;4(4):CD012662. doi: 10.1002/14651858.CD012662.pub2. PMID: 32352565; PMCID: PMC7197696.